Case 29: Osteomyelitis of First Metatarsal Head but Therapy Limited to Autoamputation of Distal First Toe

At age 39, this 307 pound six foot male was admitted to the hospital with a temperature of 102 and a swollen ulcerated foot. He had had known diabetes for 13 months and a foot ulcer almost as long. He sought intermittent care for his foot ulcer at various doctors' offices and emergency rooms almost growing accustomed to its presence. He developed fever, nausea and vomiting over the three days prior to his presentation at this time and attributed all to possible flu. In spite of swelling of his foot he continued to go to work.

Dorsum of Foot on Presentation

Shin and Plantar Ulcers

He had no palpable distal pulses. His big toe appeared to be a sallow blue and devitalized. The skin over the proximal phalanx had peeled off revealing a blackish-red soft tissue. The ulcer under his first metatarso-phalangeal joint admitted a culture probe about 3cm into the foot. The dorsum of his foot was both swollen and reddened. A small incision over the 1st MP joint released several ml of pus which eventually grew out abundant Beta-streptococcus, a few Pseudomonas aeruginosa, a few Enterococci and a few Alcaligenes species. His initial foot x-ray showed soft tissue swelling while later films showed osteomyelitis of the first metatarsal head and proximal phalanx. Initial therapy included irrigation of his abscessed area with Sea Soaks containing gentamicin, infiltration of the infected areas with gentamicin, Mini-Boot therapy with his foot immersed in Sea Soaks containing gentamicin and intravenous gentamicin and vancomycin. The intravenous administration of latter was discontinued on the 3rd hospital day and thereafter they were used only locally. Ancef was given intravenously being equally effective according to his cultures, cheaper and safer regarding his renal and ear function.

Foot at Discharge from the hospital.

At the time of discharge, the distal portion of the big toe had begun to mummify, the plantar ulcer had almost healed, the tissue beneath the black eschar over the proximal phalanx was soft and revealed a few tendons. He was discharged to allow an autoamputation of the distal big toe. He was provided with a walking cast, a prescription for ampicillin and directions to report to the office for further boot therapy. He was able to return to work and his foot healed slowly. He remained erratic in his diabetes program and maintained his massive obesity. He returned three years later with new shin ulcers and renal failure. He sought dialysis treatment elsewhere and was lost to follow-up.

Follow-up Three Years Later

Comments: In spite of his erratic behavior, this bachelor continued to have the use of his legs until he was lost to follow-up. His prognosis for life and limb remains precarious. Other practitioners in viewing his early photographs have suggested widely different outcomes than that shown here. His lack of pulses, advanced cellulitis of his foot, his osteomyelitis and his shin ulcers justify to some a BK amputation. Others suggest an open resection of his first ray. Few surgeons allow that they would have reached fifteen days in the hospital without some ablative procedure on this man.